NURSING CARE PLAN

Name of patient: MC Case: Systemic lupus erythematosus

Age: 17 years old

Cues Nursing Rationale Goals & Nursing Interventions Rationale Evaluation

Diagnosis Objectives
Decreased oxygen Short term goal: Independent:
Subjective: Activity After 4 days of  Assess client’s  Influences choice of
“Makapoy ha intolerance may carrying capacity of Hgb nursing ability to perform interventions and
lawas tas maul be related to interventions, the normal tasks and needed assistance.
ol it ak ulo.” as imbalance patient will: ADLs, noting reports
verbalized by between oxygen - Report an of weakness,
Decreased nutrition in
the patient. supply or delivery increase in fatigue, and difficulty
and demand cells activity tolerance, accomplishing tasks.
possibly evidence including ADLs.
Objective: by weakness and  Note changes in  May indicate
 lethargy fatigue Long term goal: balance, gait neurological
 tired eyes Decreased ATP At the end of 1 disturbance, and changes associated
 Temp.: production since oxygen month nursing muscle weakness. with vitamin B12
36.3°C is needed for oxidation of interventions, the deficiency, affecting
 Pulse: 78 patient will: client safety and
CHO/glucose - Demonstrate a
beats/min increasing risk of
 RR: 16 decrease in injury.
cycles/min physiological
 BP: 100/80 signs of  Monitor BP, pulse,  Cardiopulmonary
Decreased energy or
mmHg intolerance— and respirations manifestations
muscle weakness pulse, during and after result from attempts
 Hct: 0.09 L/L
respirations, and activity. Note by the heart and
 Hgb: 56 g/L
BP remain within adverse responses lungs to supply
 pO2: 29 client’s normal
mmHg to increased levels adequate amounts
Activity intolerance range. of activity— of oxygen to the
- Display increased heart rate tissues.
laboratory values and BP,
(Hgb/Hct) within dysrhythmias,
acceptable dizziness, dyspnea,
range. tachypnea, and
Reference: cyanosis of mucous
http://www.pathophys.org/ membranes and
nailbeds.
activityintolerance/
 Recommend quiet  Activity may need to
atmosphere and be curtailed until
bedrest, if indicated. severe anemia is at
Monitor and limit least partially
visitors, phone calls, corrected to lower
and repeated body’s oxygen
unplanned requirements and
interruptions. reduce strain on the
heart and lungs.

 Elevate head of bed,  Enhances lung

as tolerated. expansion to
maximize
oxygenation for
cellular uptake.
Note: May be
contraindicated if
hypotension is
present.

 Suggest client  Postural

change position hypotension or
slowly; monitor for cerebral hypoxia
dizziness. may cause
dizziness, fainting,
and increased risk
of injury.

 Assist client to  Promotes adequate

prioritize ADLs and rest, maintains
desired activities. energy level, and
Alternate rest alleviates strain on
periods with activity the cardiac and
periods. respiratory systems.

 Provide or  Although help may

recommend be necessary, self-
assistance with esteem is enhanced
activities and when client does
ambulation as some things for self.
necessary, allowing
client to be an active
participant as much
as possible.

 Plan activity  Promotes gradual

progression with return to normal
client, including activity level and
activities that client improved muscle
views as essential. tone and stamina
Increase activity without undue
levels, as tolerated. fatigue. Increases
self-esteem and
sense of control.

 Identify and  Encourages client to

implement energy- do as much as
saving techniques: possible, while
shower chair and conserving limited
sitting to perform energy and
tasks. preventing fatigue.

 Instruct client to stop  Cellular ischemia

activity if potentiates risk of
palpitations, chest infarction, and
pain, shortness of excessive
breath, weakness, or cardiopulmonary
dizziness occur. strain and stress
may lead to
decompensation
and failure.

 Discuss importance  Vasoconstriction

of maintaining with shunting of
environmental blood to vital organs
temperature and decreases
body warmth, as peripheral
indicated. circulation,
impairing tissue
perfusion. Client’s
comfort and need
for warmth must be
balanced with need
to avoid excessive
heat with resultant
vasodilation, which
reduces organ
perfusion.

Dependent:
 Provide supplemental  Maximizing oxygen
oxygen as indicated. transport to tissues
improves ability to
function.

 Administer the  Increases number

following, as of oxygen-carrying
indicated: Whole cells; corrects
blood, packed RBCs deficiencies to
(PRCs); blood reduce risk of
products as hemorrhage in
indicated. Monitor acutely
closely for transfusion compromised
reactions. individuals. Note:
Transfusions are
reserved for severe
blood loss anemias
with cardiovascular
compromise and
are used after other
therapies have
failed to restore
homeostasis.

 Erythropoiesis-  Large-scale clinical

stimulating therapies, studies have shown
such as epoetin- the effectiveness of
Alpha (Procrit, EPO) EPO in increasing
erythrocyte and Hgb
levels, relieving
clinical and quality-
of-life
manifestations
associated with
ACD (National
Institute of Diabetes
and Digestive and
Kidney Diseases
[NIDDK], 2005).

Collaborative:
 Monitor laboratory  Identifies
studies, such as deficiencies in RBC
Hgb/Hct, RBC components
count, and arterial affecting oxygen
blood gases transport, treatment
(ABGs). needs, and
response to
therapy.

 Prepare for surgical  Surgery is useful to

intervention, if control bleeding in
indicated. clients who are
anemic because of
bleeding, such as in
ulcers and uterine
bleeding; or to
remove spleen as
treatment of
autoimmune
hemolytic anemia.
Bone marrow and
stem cell
transplantation may
be done in presence
of bone marrow
failure—aplastic
anemia.

Reference: Doenges,
Moorhouse, & Murr,
Nursing Care Plans:
Guidelines for
Individualizing Client
Care Across the Life
Span 8th ed.